Cardiopulmonary, metabolic, and perceptual responses during exercise in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS): A Multi-site Clinical Assessment of ME/CFS (MCAM) sub-study by Dane B Cook, Stephanie VanRiper, Ryan J Dougherty, Jacob B Lindheimer, Michael J Falvo, Yang Chen, Jin-Mann S Lin, Elizabeth R Unger (The MCAM Study Group) in PLoS One. 2022 Mar 15;17(3):e0265315 []



Cardiopulmonary exercise testing has demonstrated clinical utility in myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). However, to what extent exercise responses are independent of, or confounded by, aerobic fitness remains unclear.


To characterize and compare exercise responses in ME/CFS and controls with and without matching for aerobic fitness.


As part of the Multi-site Clinical Assessment of ME/CFS (MCAM) study, 403 participants (n = 214 ME/CFS; n = 189 controls), across six ME/CFS clinics, completed ramped cycle ergometry to volitional exhaustion. Metabolic, heart rate (HR), and ratings of perceived exertion (RPE) were measured. Ventilatory equivalent (), metrics of ventilatory efficiency, and chronotropic incompetence (CI) were calculated.

Exercise variables were compared using Hedges’ g effect size with 95% confidence intervals. Differences in cardiopulmonary and perceptual features during exercise were analyzed using linear mixed effects models with repeated measures for relative exercise intensity (20–100% peak ). Subgroup analyses were conducted for 198 participants (99 ME/CFS; 99 controls) matched for age (±5 years) and peak  (~1 ml/kg/min-1).


Ninety percent of tests (n = 194 ME/CFS, n = 169 controls) met standard criteria for peak effort. ME/CFS responses during exercise (20–100% peak ) were significantly lower for ventilation, breathing frequency, HR, measures of efficiency, and CI and significantly higher for  and RPE (p<0.05adjusted). For the fitness-matched subgroup, differences remained for breathing frequency, , and RPE (p<0.05adjusted), and higher tidal volumes were identified for ME/CFS (p<0.05adjusted). Exercise responses at the gas exchange threshold, peak, and for measures of ventilatory efficiency (e.g., ) were generally reflective of those seen throughout exercise (i.e., 20–100%).


Compared to fitness-matched controls, cardiopulmonary responses to exercise in ME/CFS are characterized by inefficient exercise ventilation and augmented perception of effort. These data highlight the importance of distinguishing confounding fitness effects to identify responses that may be more specifically associated with ME/CFS.

Excerpt from full Conclusion:

In general, the acute exercise capacity of this cohort of people with ME/CFS was in the low-to-normal range, when considering their GET and peak aerobic capacity values. However, these data do not provide a complete functional picture of the cardiopulmonary system in ME/CFS.

Ventilatory efficiency was found to be low in those with ME/CFS and significantly worse than controls. The observed responses likely reflect adequate oxygen delivery but inadequate oxygen utilization and are suggestive of disease specific adaptations that may be of pathophysiological significance but require more research. These data also highlight the importance of distinguishing fitness effects from those that are primary to the disease. By closely matching our groups on aerobic capacity/exercise time and age, many group differences were eliminated. Importantly, our data suggest that chronotropic incompetence was not present among this large sample of participants with ME/CFS.

When considering physical activity for people with ME/CFS, clinicians face the challenge of helping patients avoid the negative effects of acute exercise (e.g., symptom exacerbation) [71, 72], while moving them towards experiencing the health benefits associated with a more physically active lifestyle [73]. A logical approach is to develop exercise prescriptions which strike a balance between minimizing symptom exacerbation and maximizing function, however, there is limited information on the intensity threshold at which this ideal balance occurs or guidance on how to establish this threshold for individual patients.

It is noteworthy that in other patient care settings for which a substantial literature on exercise prescription already exists, ramped incremental CPET is considered the gold standard for physiologically comprehensive exercise intensity assessment and prescription [74]. Given that over 90% of the present sample was able to provide a valid peak effort during CPET, we conclude that there is sufficient precedent for future work testing whether CPET guided exercise prescription can help address the unique physical activity challenges experienced by people with ME/CFS. Further, we believe that these data will support current recommendations to practitioners to encourage patients with ME/CFS to maintain tolerated levels of activity, to increase activity with caution, and make adjustments to avoid post-exertional malaise.

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